Critical Care Exam Pro Flashcards
Hemodynamic changes in pregnancy CO HR LVSWI SVR PVR MAP PCWP COP
CO +43% HR + 10% LVSWI +10% SVR- 20% PVR- 30% MAP +4% PCWP +30% COP -14%
PCWP in pregnancy
6-12
CVP in pregnancy
4-10
PVR
SVR in pregnancy
PVR- 55-100
SVR 1000-1400
LVSWI
40-55
who class 1
No increased risk
small PDA, Mild PS, repaired simple lesions, ectopic beats
who class 2
mortality 5-15% ASD/VSD repaired tet arrythmias mild left ventricular dysfunction HCM biprosthetic valve repaired coarc Marfan with aorta <40 mm BAV with aorta <45 mm
who class 3
mortality 25-50% mechanical valve systemic RV cyanotic heart disease complex CHD BAV with aorta 40-50 mm Marfan aorta 40-45 mm
who class 4
severe MS severe AS BAV with aorta >50 Marfan with aorta >45 EF <30% severe coarct severe pulmonary hypertension
Cardiac C/S indications
aortic >40 mm
AA
recent MI
severe symptoms aortic stenosis
pulmonary hypertension
25-30 mmhg lower mortality <50 lower motality with idiopathic vs cardiogenic Delivery mod/severe 32-34 weeks mild 35-37 week deliv
pulmonary hypertension treatment
ca channel blocker
NO
prostacyclin derivatives
sildenafil (phosphodiesterase inhibitors)
Endothelin receptors blockers are teratogenic
enhanced treatments for at least 3 months
what to give for PEA
epinephrine
atropine
marfan treatments
ppx b blocker
pp cardiomyopathy definition
EF<45%
fractional shortening <30 %
left ventricular end diasolic dimension >2.7cm/m
pp cardiomyopathy treatment
O2 reduce afterload- hydralazine improve contractility- dig Reduce Myocardial demand - beta blocker ppx anticoagulation - wearable cardioverter - LVAD - ECMO
- recovery 50-75%
AA 20-45%
mortality with subsequent pregnancys with a history of PPCM
recovered- 20% reoccurance 0% mortality
decreased function
- 40-65% will have reoccurance
15% mortality
In general what are high risk maternal cardiac lesions
aortic regurgitation/mitral regurg with NYHA class III/IV
Marfan syndrome (expecially with aortic regurg)
Severe aortic stenosis <1.5 cm, gradient >30 mmhg
Severe Mitral Stenosis <2 cm
LV dysfunction (pulmonary hypertension, EF decreased,
Mechanical valves
Poor functional class or cyanosis
Goals in sepsis
CVP 8-12
MAP> 65 mmhg
normalize pulse
uop >0.5ml/kg/hr
SIRS
Fever, tachycardia, tachypnea, leukocytosis, mental status change, hyperglycemia
Septic shock
hypotension persists despite adequate fluid resuscitation
Severe sepsis
sepsis wih organ dysfunction O2 requirement Oligouria Elevated creatinine >1-2 Hypotensive Plt<100,000 Lactate>2 (>4 very bad) Bilirubin >2 INR>1.5
sepsis
SIRS from septic shock
Sepsis treatment
fluids 20-30 ml/kg/hr
start with 20 and repeat as needed with 500 cc/bolus
-pressors as needed ( norepi)
Lung volumes TLC VC RV FRC
changes in pregnancy
TLC- total VC- how much can be exhaled RV- left after VC FRC- left after normal breath ERV- FRV- RV
decreased ERV/FRC/ RV VC preserved Incrased TV RR unchanged minute ventilation > 50%
- avoid over ventilation goal pCO2 30-32
pregnancy ABC PaO2 PaCO2 HCO3 pH
PaO2- 101
PaCO2-up to 32
HCO3- up to 21
pH- 7.4-7.45
DDX of dyspnea
allergic reaction aspiration pulmonary edema PE AFE maternal heart disease
mild asthma
<1 hour
<2 episodes/week
PEFR>80%
mild persistant
> 2x week
Immunospressive medications in pregnancy
immunosuppression regimen in pregnant transplant recipients is the combination of a CNI (either tacrolimus or cyclosporine), azathioprine, and low-dose prednisone
The use of mycophenolate mofetil, sirolimus everolimus- not recommended
SLE treatment pregnancy
hydroxychloriquine
-prednisone
- can consider tacrolimus, cyclosporine, azathioprine
zahara score
arrhythmias 1.5 NYHA class II 0.75 Left heart obstruction 2.5 Cardiac medication 1.5 Systemic AV valve 0.75 Pulmonary AV valve 0.75
0-2.9% 0.5-1.5 7.5% 1.51-2.50 17.5% 2.51-3.50 43.1% >3.51 70%
Carpreg
Prior heart failure, TIA, stroke before pregnancy -1
NYHA III/IV -1
Valvular and outflow tract obstruction
AV<1.5, MV <2 LVOT gradient >30 - 1
Myocardial Dysfunction
LVEF <40%, Cardiomyopathy -1
Mortality
0- 5%
1 - 27%
>1 -75%
NYHC
1- normal
2- fatigue with physical activity
3- fatigue with daily life
4- uncomfortable at rest
Bacterial endocarditis ppx
prosthetic heart valve
prior infective endocarditis
unrepaired congenital heart disease
repaired CHD for 6 months after repair with prosthetic material
- discuss with cardiology
ppx is ampicillin
why is vaginal delivery perferred in cardiac disease
decresed blood loss decreased pain decreased fluid shifts decresed immobilization decreased thrombosis
how do you alter labor management with cardiac disease
labor in lateral decubitus
“slow” epidural (maybe not aortic stenosis)
work up for palpitations
EKG
thyroid
UDS
- caffeine, smoking, alcohol use
Pulmonary hypertension for esingmenger pearls
decreased SVR will cause worse R to L shift and potentially death due to lack of oxygenization
NO/intravenous prostacyclin reduce PVR
Anticoagulation
delayed death can be seen 4-6 weeks
Non-cardiogenic pulmonary edema
preeclampsia ARDS Sepsis DIC TRALI Anaphylaxis AFE
Cardiogenic reasons for pulmonary edema
CHF Cor Pulmonale Myocardial infarction CHD Aquired valve lesions Ischemic heart disease Dysrhythmias Hypertension Intravascular overload B mimetic multifetal
what is ARDS
decreased lung compliance with massive intrapulmonary shunting
- in OB likely infection
P/F ratio <200
P/F ratio - looking for intrapulmonary shunt
blood flow but lung that is not oxygenated
PaO2/FiO2 x100 =P/F ratio
high -good
low- bad
Inital Vent settings
SIMV
Goals
Rate 14-16
Tidal volume 6-10 ml/kg
PEEP 5
Goals: PaO2 >60
SaO2 >95
PaCO2 30
Group A Strep
most pp
hypothermia
pain out of proportion
Nec Fash
- take out the uterus!
Indication for intubation
oxygenation - PO2 <60 ventilation PCO2 >40 maternal exhaustion Worsening acidosis altered conciousness
ScVO2
how well is tissue being extracted
- >70%
eval by Central venous cath
opioids for athma
fentanyl
